Appeal and Grievance Coordinator

This is a fully remote position, open to applicants in Oklahoma.

📋 Description

• Review, investigate, and address appeals, complaints, and grievances across all product lines.

• Facilitate responses from various business units for cases involving multiple concerns.

• Examine incoming electronic appeals, complaints, and grievances, and redirect inappropriate work items.

• Assess benefit or administrative denials by reviewing plan design and certification of coverage.

• Investigate claim processing logic, member eligibility information, and billing/payment statuses.

• Analyze all elements of member and provider/practitioner cases.

• Assign incomplete case components to the relevant subject matter experts.

• Manage final communications, resolutions, and closures with members and providers.

• Act as a technical resource for colleagues on intricate appeals, complaints, and grievance matters.

• Detect trends and emerging issues, document findings, and propose potential solutions.

⛳️ Requirements

• Candidate must reside in Oklahoma.

• High School diploma or GED equivalent is required.

• 1–2 years of relevant experience in claims platforms, products, and benefits; patient management; drafting of products or contracts; compliance and regulatory analysis; special investigations; provider relations; customer service; or audit work.

• Experience in interpreting or researching benefit language is essential.

• Capability to thrive in a fast-paced environment with stringent deadlines.

• Ability to make sound decisions in line with existing policies and guidelines.

• Comprehensive knowledge of member and/or provider appeals, complaints, and grievance policies.

• Strong analytical abilities with a focus on accuracy and detail.

• Familiarity with clinical terminology, regulatory standards, and accreditation requirements.

• Excellent verbal and written communication skills are a must.

• Proficiency in computer applications, including Excel and Microsoft Word.

• Some college education is preferred.

• Experience in researching and analyzing claim processing is desirable.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources supporting physical, emotional, and financial well-being.